Optimizing Secondary Stroke Prevention in the Hospital and Throughout Managed Care

ALPESH N. AMIN, MD, MBA
Associate Dean for Clinical
Transformation
UCI Heath

Professor and Chief
Hospital Medicine and
Palliative Medicine
UCI School of Medicine
Irvine, CA

AJMC®: How commonly do you see patients or treat patients for recurrent stroke in the hospital setting?

AMIN: In the hospital setting, approximately 15% to 30% of patients experience a recurrent stroke within 2 years; the survivability rate for ischemic stroke is around 80% to 85%. However, the frequency of encountering recurrent stroke cases can vary significantly; it is influenced by factors such as the patient’s follow-up care in the ambulatory setting and specific risk factors like hypertension and atrial fibrillation. Adherence to treatment and lifestyle choices also plays a crucial role in determining the likelihood of recurrence. Patients with factors that put them at higher risk are more likely to present with recurrent strokes that require hospital management, whereas those at lower risk typically transition to prevention-based outpatient care.

AJMC: Do you find that patients are seen less frequently in the inpatient setting than in the outpatient care?

AMIN: Yes. We primarily encounter patients during acute events when they present through the emergency department (ED). These patients are assessed for stability over 24 to 48 hours, particularly if there are no complications like bleeding or ongoing symptoms. Most patients are admitted to the hospital for further care, although, in rare cases, some may be placed under observation status. Therefore, our interactions with these patients in the inpatient setting are generally limited to acute situations rather than ongoing management.

AJMC: How might inpatient treatment for stroke and recurrent stroke differ from outpatient treatment?

AMIN: There are several key differences. In the inpatient setting, acute management is critical; it requires careful monitoring of the patient’s blood pressure and overall stability, and may require the administration of thrombolytics that would not be provided in outpatient care. Diagnostic testing such as CTs, MRIs, and angiograms is generally more accessible in the hospital, facilitating prompt assessment and intervention. In addition, inpatient care often involves a multidisciplinary team including hospitalists, neurologists, pharmacists, nurses, and rehabilitation specialists, which enhances the comprehensive care approach during acute episodes. Preventive measures such as initiation of anticoagulants or antiplatelet agents—some of which can be administered intravenously—are also prioritized in the hospital. Furthermore, the inpatient phase emphasizes the transition and continuity of care, including short-term rehabilitation for functional recovery. In contrast, outpatient care focuses on chronic management that addresses long-term issues like diabetes, hypertension, and lifestyle modifications along with extensive patient education and family support to ensure a solid care network. Overall, while both settings require patient education and multidisciplinary involvement, the inpatient approach is more acute and immediate, while outpatient care emphasizes ongoing management and rehabilitation.

AJMC: The American Heart Association/American Stroke Association (AHA/ASA) guidelines provide a foundation for secondary stroke prevention.¹ What specific challenges to implementing these guidelines arise in the hospital setting?

AMIN: Implementing the AHA/ASA guidelines for secondary stroke prevention presents several challenges not only in hospitals but across the entire health care system. Effective patient care involves multiple touchpoints including the ED, hospital floors, intensive care unit (ICU), and various outpatient settings like rehabilitation and primary care. This interconnectedness highlights the critical need for coordinated care, which the guidelines emphasize but which often faces hurdles. Communication gaps frequently arise, particularly when electronic medical records (EMRs) differ between hospitals and outpatient facilities and complicate information sharing. Resource limitations further complicate care transitions, especially for patients not enrolled in well-structured managed care programs. For these individuals, care pathways may be inconsistent, hindering access to medications and services essential for recovery. Additionally, patient-level challenges such as medication adherence and lifestyle modifications pose significant barriers as many patients struggle to change long-standing habits. The guidelines also call for the elimination of social and economic barriers, which can be deeply entrenched. Furthermore, health literacy and cultural sensitivities present ongoing challenges in patient education. While the AHA/ASA guidelines provide valuable recommendations, their successful implementation is impeded by these multifaceted challenges within the health care continuum.

AJMC: How might hospitals implement standardized pathways or protocols for stroke patients to ensure adherence to secondary prevention guidelines, and how can they effectively manage transitions to subsequent care?

AMIN: Standardized pathways play a crucial role in ensuring effective multidisciplinary communication and meeting the needs of stroke patients. By adopting these pathways, hospitals can shift from a reactive to a proactive approach in patient care to clarify the roles and responsibilities of the entire health care team that includes physical therapy, nutrition, medication management, and nursing care. This proactive framework aids in planning follow-up care and patient disposition and aligns expectations for both patients and their families. Well-developed pathways can also include standardized educational materials tailored to different literacy levels, ensuring that both the healthcare team and patients receive consistent information. Integrating these pathways into EMR systems allows for better organization and prompts for the health care team about upcoming tasks. Additionally, initiating the discharge planning process upon admission helps to maintain a clear line of sight for patient transitions. Pathways facilitate data monitoring by enabling the collection of relevant information throughout a patient’s journey from hospitalization to outpatient care especially when using a closed EMR system. These data can be leveraged to refine pathways and improve patient outcomes, ensuring adherence to appropriate medications and follow-up care. Furthermore, standardized pathways assist in managing transitions across various care settings, including the ICU, outpatient clinics, and rehabilitation facilities, to provide a structured approach to continuity of care.

AJMC: What roles do value-based care models play in improving stroke outcomes while managing costs?

AMIN: Value-based care models offer a framework for aligning the interests of all stakeholders in stroke care, emphasizing that value extends beyond profit and cost savings. One common definition of value is the equation: Value equals quality times service, divided by cost. This means that improvements in quality and service enhance value, even if cost reductions are not immediately evident. Therefore, understanding this definition is crucial for all parties involved. Value-based care fosters alignment in thought, action, and interaction that potentially leads to exponential gains in outcomes. To achieve this alignment, incentivization plays a significant role alongside the necessary investments in systems and resources to meet desired outcomes. In stroke care, value-based programs encourage data-driven approaches that prioritize patient-centered and coordinated care, ultimately improving quality. For example, our institution was among the pioneers in establishing a comprehensive stroke program, focusing on high-quality coordinated care and preventive measures. While measuring cost can be complex, sophisticated systems can begin to assess these aspects over time. Additionally, value-based programs promote collaboration among providers, managed care organizations, community resources, and ambulatory care settings, thereby creating a comprehensive support network for stroke patients. Overall, these programs represent an opportunity to transform stroke care delivery through enhanced collaboration and a commitment to achieving better patient outcomes.

AJMC: How do you balance recurrent, noncardioembolic stroke prevention with bleeding risk? Are there particular cases in which the current therapies fall short?

AMIN: Balancing recurrent noncardioembolic stroke prevention with bleeding risk is a complex challenge, as many risk factors contribute to both thrombosis and bleeding. This overlap necessitates careful evaluation of the patient’s overall risk profile. Typically, the emphasis has favored managing thrombosis over addressing bleeding risk. In discussions with patients and health care providers, a common sentiment emerges: many would favor a bleed vs a stroke. This is because bleeds can usually be stabilized, whereas stroke complications are often permanent. Fortunately, newer anticoagulants and antiplatelet agents are being developed to minimize bleeding risks while optimizing thrombosis management. The focus is often on significant bleeding events like subdural or epidural hemorrhages, but these are generally linked to specific risk factors such as falls or concurrent use of other medications that increase bleeding risk. Ultimately, a comprehensive assessment of all contributing factors is essential for effective management in stroke prevention.

AJMC: Do data analytics currently play a role in your practice, and would you like them to have a bigger role?

AMIN: Data analytics do play a role in my practice, although I see opportunities for much greater integration. Currently, we use existing analytics, but I envision a future where predictive analytics continuously guide patient care, particularly as we manage conditions over the long term. By leveraging data specific to each patient’s risk factors and lifestyle, we can make more personalized recommendations. I would like to see analytics empower patients, enabling them to track their progress toward health goals and identify areas needing more focus. While we are starting to gather data through wearables, EMRs, and insurance information, we must enhance our approach to use this data effectively for real-time improvements in patient care.

AJMC: How do you envision artificial intelligence (AI) transforming the landscape of health care delivery and patient management in the future?

AMIN: AI is poised to play a significant role in health care as it continues to evolve. As machine learning and AI technology advance, the tools we develop will become increasingly sophisticated and precise, allowing us to act on data more effectively. For instance, in industries like banking, we’ve transitioned from paper to nearly fully electronic systems, where advanced tools help manage finances seamlessly. Similarly, in aviation, pilots now spend less time navigating and more time monitoring data from AI-driven systems. This evolution indicates that AI has the potential to enhance decision-making and patient treatment in health care. As we adopt these advanced technologies, we can expect improvements in patient management and outcomes.

AJMC: What are the top strategies that you would recommend managed care organizations implement to effectively reduce the risk of recurrent strokes?

AMIN: I recommend focusing on 3 key strategies for managed care organizations to reduce the risk of recurrent strokes: education, engagement, and empowerment—what I like to call The 3 Es. First, patient education is critical; we need to ensure that patients and their support systems fully understand stroke risk factors, symptoms, and necessary lifestyle changes. This knowledge is foundational for effective management. Next, engagement is about getting patients to recognize the importance of adhering to their treatment plans and making lifestyle adjustments. We want them to understand the why behind these changes, which can significantly impact their willingness to follow through. Finally, empowerment involves providing patients with data and tools that enable them to take ownership of their health. When patients receive feedback on their progress, they become more active participants in their care, fostering a sense of partnership in the health care process. Additionally, I suggest implementing a comprehensive care coordination program that brings together a multidisciplinary team to eliminate communication gaps and facilitate seamless transitions between care settings. Finally, we should leverage advanced data analytics for real-time monitoring and interventions, which can help identify risks and optimize treatment plans. Together, these strategies can create a more effective framework for stroke prevention and significantly improve patient outcomes.

REFERENCE

1. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. 2021;52(7):e364-e467. doi:10.1161/STR.0000000000000375